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ApplicatTonsWill Be Processed-When'Submitted Properly Complete S e To S g The Applicat'- <br /> FOR�6FFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) JAN 24 1980 <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERiMA-AN InA t <br /> (CAL(COMPETE IN TRIPLICATE) WATER QUALITY HEALTH- <br /> ' <br /> Application is hereby made to the San Joaquin Local Health District foraIpermit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordignce Na. 1862 and the rubs and regulations of the San Joaquin Local Health District. [.7 <br /> Exact Site Address r2o� 6 � r City/Town .++ <br /> Owner's Name � <br /> Address Phone �7SW <br /> City_ / ) <br /> Contractor's Name w License#�79D7� } <br /> Business Phone —.2.ZL7T <br /> Contractor's Address `/►� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN 1:1 RECONDITION 1:1DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank - Sewer Lines;-,. Pit Privy — <br /> �; <br /> Sewage Disposal Field Cesspool/Seepage Pit Other ` <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> © DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> ❑ DISPOSAL Type of Grout <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done V <br /> PUMP REPAIR: IR State Work Done <br /> DESTRUCTION OF WELL: i <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District, <br /> Homeowner or licensed agent's signature certifies the following:'; certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." r <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this r <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California-" <br /> will ca r a out In do for-to grouting and a final inspect' - n <br /> rt <br /> Signed X Title: <br /> Date: <br /> (Draw Plot Plan on everse Side) # <br /> 4FO:��RTMENT USE ONLY # <br /> PHASEI i <br /> Application Accepted By Q� Q <br /> Additional Comments: Date <br /> Phase II Grout Inspection ase III Final Inspection tiT <br /> Inspection By DateInspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UN17. ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8&Received By July 31 <br /> BASE 'EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE- CHECKED - <br /> FEE _�G r AMOUNT <br /> LESS �� <br /> J <br /> PRORATION <br /> PLUS <br /> PENALTY ;I , <br /> OTHER <br /> OTHER f <br /> ii <br /> Received by -.. Dat6 Receipt No. Permit No. Issuance Date <br /> Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH-PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 Delivered <br /> CA 95201 <br />